PowerPoint Presentation

Evidence-Based DentistryPresenters Name

Introduction.

Hello everyone. I am here today to talk to you about Evidence-Based Dentistry

What does EBD mean?

Script:Id like to start this presentation by understanding your perceptions and thoughts when someone uses the term Evidence-Based Dentistry. What does EBD mean to you? >

Note to Presenter: By posing this question and asking for comments, you can shed light on attendees varied opinions and preconceptions before proceeding. Once a few people respond please summarize what you heard.

Three Components of EBD Is an approach to oral health care Is a method to acquire, understand and apply the most current science

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Script:

If we think about Evidence, Clinical Expertise and Patients Needs and Preferences as three circles then EBD is right in the center where all three circles overlap

It is important for us to understand that EBD is an approach to practice, an approach to making clinical decisions and is just one component used to arrive at best treatment decisions.

EBD is a method to stay up to date on the current science.

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The Clinicians Role

InformationDataStatisticsKnowledgeJudgmentValuesDecisionsInforms

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Script:

Sometimes it is not clear how the clinicians expertise is incorporated into EBD.

Science is data, information, statistics and knowledge.It does not have judgments or values, and it cannot tell us what to do. That is the role of the dentists. He/she must understand the data, and the information revealed with the data. This is incorporated with judgments and values to develop recommendations and help a patient make a decision about his/her individualized treatment.

The danger is in ignoring the science. Science should be embraced and utilized to form the basis for clinical decisions. It informs, but does not dictate, decisions. The clinician forms the judgment on how the science can be applied, and the patients needs and preferences form the value-basis for the individualized decision.

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Acknowledging the Difference

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Script:

In traditional practice, we dont actively look for emerging evidence, we depend on what we learned in school or what we hear speakers say. We never ask if the speaker is talking from his experiences and his study findings or if his presentation is based on a systematic assessment of all the evidence. We look for Yes/No answers.

In contrast, EBD is about using the best available evidence after a systematic assessment of the literature and accepting that sometimes we dont have the answers and we should be ready to change when these answers are found.

Such a process is a change in perspective i.e. we need to begin to look at things in a different way.

Note to presenter: Please try to use an example from your experience highlighting these differences.

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The Value of Evidence-Based Practice

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Note to presenter: A short story on why you became interested in EBD would help the audience associate with this presentation. You may also use an example of a clinical situation when you used evidence to manage a patient.

Some talking points include:As a practitioner you gain Improved clinical decision-making capability Greater self-confidence in treatment planning Satisfaction derived from creating customized treatment plans Greater respect from improved communication with patients

Your Patients gain More trust and confidence in you and your practice Greater incentive to invest in quality oral health care Increased pride from being a patient of a community thought leader and a distinctive practice

Your Dental Team and Practice gainIncreased staff confidence, pride, trust and personal satisfactionEnhanced recognition in the community and with peers Greater opportunity to conserve practice financial resources by enabling wiser decisions in product, equipment and therapeutic selections

Barriers to changeTime

Access

Complexity of information

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Script:Understanding the changes and a willingness to move forward puts us face to face with the challenges that confront us.

But this needs time. I know I dont have time. In the course of running a busy practice, it is difficult to find the time to conduct a literature search, read all identified articles, critically assess the articles, and come to some conclusion

Even if I have time, the typical private practice or small practice nature of most dental offices does not provide access to a wide variety of journals.

Finally, many articles published in scientific formats are not user-friendly for chairside application

But these are just some walls we need to learn to climb. The ADA and many other agencies offer several resources to help apply evidence in practice. So our goal should be to find such sources and use this information.

If you have limited time, consider starting with clinical practice guidelines and the secondary sources of evidence such as summaries and systematic reviews. (Note that a list appears on Slides 32, 33 and 34)

What is evidence?

Script:Now, lets move on to understanding evidence.

The dictionaries define evidence as an outward sign or something that furnishes proof.

For a moment lets all go to court!

Now in a court of law we often hear the words circumstantial evidence or hearsay evidence.

So there are different types of evidence, some of which serve as better proof than the others.

Coming back to health care, we also have different levels of evidence.

Because the appraisal and evaluation of evidence takes skills that are improved over time, we can think of evidence in two categories: PRE-APPRAISED and PRIMARY.

What is pre-appraised evidence?

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ScriptPre-appraised evidence means that the evidence has been evaluated according to standard methods by a group of experts with experience and skills in the area of evidence-based dentistry. The ADA offers two types of pre-appraised evidence: clinical practice guidelines and critical summaries of systematic reviews; and also a database for easy access to systematic reviews. Note that the ADA also generates its own systematic reviews as the foundation for the clinical practice guidelines.

Clinical practice guidelines are statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options. At the ADA, the Council on Scientific Affairs appoints an expert panel including stakeholders to develop the guidelines according to a comprehensive and transparent process.

Critical summaries of systematic reviews are developed by trained ADA Evidence Reviewers mentored by evidence-based dentistry experts called the Critical Review Panel. These summaries are one-page snapshots that provide an overview of the systematic review, an assessment of both the level of evidence on the topic as well as the quality of the systematic review, and the clinical implications of the information.

In a systematic review, the authors try to identify all evidence on a particular topic and analyze the data cumulatively. The advantages of this type of document are that it is based on multiple studies not just one, it follows a systematic process, and it provides a big picture of what ALL the evidence on a topic points to.

Systematic reviewsImplementation into clinical practice1. Clinical Practice Guidelines2. Critical summaries of systematic reviews

3. Independent appraisal of systematic reviews (and/or other trials)Tiered approach to finding evidence-based information

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The Center for EBD promotes a 3-step process to find evidence. You should first look for Clinical Practice Guidelines on the question of interest.

If none exist, then you should look for Critical Summaries of systematic reviews on the topic.

Finally, if those are unavailable you then need to perform your own literature search to find relevant systematic reviews which you would need to critically appraise and interpret independently.

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How do I find the best evidence-based information to guide my practice?

Script:So, you are probably asking, how do I find the best evidence-based information to guide my practice given all the barriers that I face?

Script:

One of the easiest ways to access evidence is to search the ADAs EBD website. This website has some of the highest evidence available in dentistry. It includes guidelines and summaries of systematic reviews, both of which can help you quickly access evidence and use it clinically.12

ADA clinical practice guidelines

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The ADA has six clinical practice guidelines published.Five are caries-prevention focused, including:Topical fluoride update (2013)Non-fluoride caries preventive agents (2011)Infant formula (2011)Fluoride supplements (2010)Sealants (2008)The sixth is on screening for oral cancer (2010)A new guideline on nonsurgical treatments for chronic periodontal disease as well as an update on the sealants guideline are currently being developed.

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Script: The EBD website also has critical summaries of systematic reviews. Critical summaries are short, easy to read sources of information written by people trained by the ADA. They include a summary of the methods and conclusion of the systematic review, critical appraisal so that we know how good the systematic review is AND how good the evidence is, and clinical implications to help us decide how to use the evidence when treating our patients.14

What are the levels of primary evidence?

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ScriptIf there are no clinical practice guidelines, critical summaries, or systematic reviews on your topic of interest, then you need to look to primary evidence to answer your clinical question.The level of evidence does depend on the question that you are asking; however, traditionally evidence is depicted according to a pyramid, where higher levels on the pyramid represent higher levels of evidence, which in turn indicates a lower risk for bias.

The highest level of primary evidence is a randomized controlled trial or an RCT. This is the highest level of a clinical study.

If a trial is not randomized, but it has a control, then it falls one level below the RCT.

There are other types of clinical studies like the cohort studies, case control, case series and case reports, which are called observational studies.

Right under the clinical studies are the expert opinions especially those developed through consensus panels followed by animal research and bench-top research.

In an IDEAL world we prefer RCTs to answer all our questions, especially with respect to what interventions perform the best?.

How does EBD work?

Script:So how does one implement EBD?16

The EBD Process

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Note to presenter: This slide includes an animation which will work with each click of your mouse. Please try out.Script:

The first step is to define a clinically relevant, focused question. In defining a question we must pay attention to four elements what is the population (children/adults or smokers/non-smokers etc.), what is the intervention, what are we comparing it to and what is the outcome that we need?

The second step focuses on systematically searching for evidence published or unpublished, that may help to answer this question.

The third step of the EBD process is focused on appraising the validity and reliability of the evidence. Important questions to ask at this point What is the level of evidence used to come to the conclusion? Does this apply to my patient?

The fourth step of the EBD process involves using the evidence in treatment planning. Based on my clinical expertise, and the patients needs and preferences, how strongly should I recommend this to my patient?

The final step involves assessing treatment outcomes for the patient.

Population or ProblemStep 1: Framing the Answerable QuestionPI COIntervention

Comparison (Optional)Outcome

SCRIPT:

The clinical question is usually asked in a PICO format. P is the population of interest. I is the intervention. This can be thought of as the new treatment that is being studied. C is the comparison treatment. And O is the outcome. You can think of this as what exactly is being measured.

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Framing the questionIncrease chances of finding the answerKnow when youve found the answerHelp to find it quicklyIdentify search terms

Script:

Why is a PICO question important?

A PICO question helps to focus and frame your question. It increases your chance of finding the answer, and finding it quickly. By having a searchable question, you can identify key words to use for searching. And lastly, it will help you know when youve found the answer to your question. When used effectively, PICO questions can make searching for answers easier and faster.

Now, lets practice..19

In patients with periodontal disease, will short-term systemic antibiotics, when compared to surgery, reduce pocket depth?

Population

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Now, lets run through an example. In this question, can you identify the POPULATION?20

In patients with periodontal disease, will short-term systemic antibiotics, when compared to surgery, reduce pocket depth?

Population

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In patients with periodontal disease, will short-term systemic antibiotics, when compared to surgery, reduce pocket depth?

Intervention

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What is the INTERVENTION22

In patients with periodontal disease, will short-term systemic antibiotics, when compared to surgery, reduce pocket depth?

Intervention

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In patients with periodontal disease, will short-term systemic antibiotics, when compared to surgery, reduce pocket depth?

Comparison

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What is the COMPARISON?24

In patients with periodontal disease, will short-term systemic antibiotics, when compared to surgery, reduce pocket depth?

Comparison

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In patients with periodontal disease, will short-term systemic antibiotics, when compared to surgery, reduce pocket depth?

Outcome

SCRIPT:

What is the Outcome?26

In patients with periodontal disease, will short-term systemic antibiotics, when compared to surgery, reduce pocket depth?

Outcome

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SCRIPT:

The next step in the EBD process is accessing the evidence. There are many ways to do this, and searching is a skill that needs to be developed and refined over time. 28

EBD website ebd.ada.orgYESSTOPEBD website and PubMedYESSTOPPubMed(Clinical Studies)YESSTOPSEARCH STRATEGY

Script:

When searching for evidence, one strategy is to look for summaries and guidelines first. If you can get an answer to your question, then you are done! The primary website that can be used to search for guidelines and summaries is the ADAs EBD website.

If you do not have an answer to your question, the next step is to search for systematic reviews. The EBD Website is the first place to look for systematic reviews since its database only includes dental systematic reviews. But if you dont find your answer there, then the next place to look is PubMed.

If you do not find any systematic reviews answering your question, then the next step is to look for primary studies on PubMed.

This strategy allows you to look for the simplest source of evidence first, documents (guidelines and summaries), where someone else has critically assessed a wide amount of evidence. Only if you dont find an answer do you need to start looking for and searching more complex websites.29

SCRIPT:

The next step in the EBD process is to critically appraise the evidence. Not all studies are created equal, and we need to understand the strengths and weaknesses of each study. This is a learned skill, and one of the other advantages of using guidelines or summaries is that someone else has critically appraised the research for you. But if you do not find a guideline or summary, you will need to take the time to read an article, especially the methods section, to determine the quality of the research. 30

Other levels of evidence

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Script:

Well then, why cant we only use RCTs for evidence? The simple answer of course is because our world is not ideal!

But specifically because:One, RCTs may not be available. RCTs have not been conducted to address all clinical questions.

Two, they may not be applicable. There are circumstances where an RCT is either unnecessary or unethical to answer a clinical question. A typical example is that there is no need to do an RCT to determine if using a parachute will save lives when jumping from an airplane. We know the answer to this without doing an RCT.

Sometimes after a systematic assessment of the literature if we find that expert opinion is THE ONLY evidence available it is graded as a weak level of evidence. In such a situation we accept the levels of uncertainty and use our judgment to determine how strongly we might recommend this approach to our patients. We understand that further research is needed in this case and that results may very likely change the way we might approach a similar situation in the future.

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SCRIPT:

The next step is to decide whether or not to apply the evidence in practice. To do this you need to consider three questions..32

Are the results valid?QualityAre the studies well designed and executed?What types of studies are there?QuantityHow many studies are there?What are the population sizes?ConsistencyHow consistent are their results?

Script:

The first question is: Is it VALID? For this you want to look at the quality of the study (this is the critical appraisal), the quantity (the number of studies and the number of subjects), and the consistency (do all the studies have similar results?).

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Are the results valid?

What are the results?Certainty of the effect

Magnitude of the effect

Script:

The second question is: What are the RESULTS? For this you want to determine how certain the researchers (and you) are about the results, and also how large the results are. 34

Are the results valid?

What are the results?

Can the results be applied to my patient?Is the population similar?

Is the provider similar?

Is the setting similar?

Script:

The third question is: Can the results be APPLIED to my patient? For this you want to understand if the population, provider and setting are similar. If so, then you can expect to have similar results with your patients.35

SCRIPT:

The final step in the EBD process is Assessing the results. This is understanding what impact the treatment has had on your patients. Did it work? If not, why?36

EBD Champions 2.0Implementing Science in Practice

Script:

For anyone wanting to learn more about EBD, Id recommend the ADAs EBD Champions Conference as a start. This is a great introductory conference about EBD, and has a very successful track record. It is a mix of lectures and several hands-on learning exercises so that you can begin to develop new skills. It is also a great way to network with other dentists interested in EBD.

Note to presenter: please personalize this and include information about your experience at the EBD Champions conference37

Script:

The EBD website also has many video tutorials about EBD. These are quick, 5-10 minute videos, about things like using the EBD website, statistics and applying EBD in practice. They dont take much time, and you can learn at your convenience.38

"Perhaps the best course of my dental career.

"Highly recommend the program . . . a great means of extending the practice of EBD."Advanced Evidence-Based Dentistry Workshop: Assessing the Quality of Evidence

Script:

In collaboration with New York University, the ADA is offering a 1 week intensive EBD workshop. This is the same workshop that originated at Oxford University, and was originally brought to the U.S. by the ADA and The Forsyth Institute. This is where you can really learn the skills of critically reading and appraising studies. This is for those who are ready to roll up their sleeves with EBD!39

The better the research, the more confident the decision. Victor Montori, Mayo ClinicEvidence alone is never sufficient to make a clinical decision. Victor Montori, Mayo ClinicExternal clinical evidence can inform, but can never replace, individual clinical expertise. David Sackett

SCRIPT:

In closing, here are some quotes that will help us reflect on the importance of EBD, and how we can use it when treating our patients.40

THANK YOU!

ADA Contact: ebd@ada.org

Script:

I hope I provided you with enough information to interest you in EBD and help you apply this approach in your practice. Please feel free to contact the American Dental Association if you are interested in any of their programs.

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